Note from Dr. Glazer: The authors of this paper are clinicians who, with the cooperation of the patients and staff at their institution, have been persistently following a stepwise process to identify a best practice in the area of inpatient safety. A previous column by these authors, in the April 2007 issue, delineated their concept of inpatient safety guidelines. In this column they describe the guidelines that they adapted and implemented. They demonstrate, through integration of data from their risk management and human resources records, the potential impact of these guidelines once implemented. It is now time for some controlled trials that will promote this work to the status of a best practice.
Threatening or violent patient behaviors in psychiatric treatment facilities can result in injuries to staff and patients, which create substantial treatment, occupational, and financial challenges for mental health administrators (1,2). Health care workplace injuries during the treatment of psychiatric patients occur when the interaction of individual, social-psychological, interpersonal, situational, and contextual variables are not properly managed (3,4).
The Joint Commission's 2008 National Patient Safety Goals for Hospitals Standards recognizes that sound treatment design is intrinsic to the delivery of safe, high-quality inpatient services; goals to decrease and eliminate staff injuries should focus on systemwide, evidence-based solutions (5). In the spirit of the Joint Commission's national patient safety goals, this column describes the implementation of safety guidelines developed for the injury-free management of psychiatric inpatients in a hospital system during precrisis and crisis treatment. The guidelines were developed for use at Twin Valley Behavioral Healthcare (TVBH), an inpatient treatment facility for approximately 200 civil patients, forensic patients, and maximum-security forensic patients of the Ohio Department of Mental Health (ODMH).
These guidelines are based on the safety concepts described in our previous contribution to the Best Practices column (6). In this column, we describe them and demonstrate their validity in a quasi-experimental study. The goal of the guidelines is to create a "culture of safety" in all hospital settings and interventions.
TVBH benchmarks the quality of its services with national standards and the other four regional, state-operated, psychiatric ODMH hospitals. In the fall of 2003, TVBH determined that its direct care staff was experiencing a disproportionately higher rate of lost workdays as a result of staff injuries; 90% of the injuries were related to staff-patient physical-contact interventions, and 50% were specifically related to use of the patient restraint process. To reduce staff injuries, TVBH developed the Safety Guidelines for Injury-Free Management of Patients in Precrisis and Crisis Situations. The guidelines' safety rules were implemented in 2004 with multimedia training sessions and incorporated into TVBH policies with an agency logo: "Working Smart=Working Safe." This logo was incorporated into all TVBH orientation, educational, and training documents and serves as the initial sign-on wallpaper for all staff desktop computer workstations. [A graphic of the logo is available in an online supplement to this column at ps.psychiatryonline.org.]
Each year TVBH staff are interviewed and surveyed to obtain input for effectiveness to update the guidelines. During the period 2004—2008, the number of staff injuries, incidents defined as recordable by the Occupational Safety and Health Administration (OSHA), and the number of individuals with lost workdays were recorded and analyzed.
The TVBH quality assurance office aggregates and analyzes all incidents. The quality assurance patient safety coordinator monitors all reports for any incidents related to patient or staff injuries and ensures that all incident reports are accurate, complete, and comprehensive. The safety and health inspector and personnel from the Human Resources Department manage the records and procedures for individuals with lost workdays. Other productivity outcomes measured were reduction of restraints and seclusions, use of emergency medications, and use of precrisis interventions to de-escalate events.
The eight elements of care and practice
The TVBH safety guidelines are based on eight elements of care and safety practice. The guidelines emphasize that the development of a therapeutic relationship between staff and patient is critical to the success of maintaining a treatment milieu that is safe.
Element 1: patient-affirming and respectful interactions with staff. Staff and patient interactions must be affirming and respectful, acknowledging the patient's control and ability to do the right thing; this is essential to the patient's recovery. Staff must be firm, and if it is necessary to be firmer or more directive, staff should avoid using negative words such as "no," "won't," "can't," and "don't."
Elements 2 and 3: avoid physical intervention and seek early assistance. Staff must avoid using physical intervention—particularly a one-person staff intervention—and request early assistance from other staff. A higher risk of injuries exists when staff members place hands on a patient or attempt to manage a potentially threatening situation alone. Physical intervention is to be avoided unless necessary to preserve safety.
Element 4: requirements for physical intervention when therapeutically necessary. When physical intervention is therapeutically necessary to preserve or protect someone's safety, authorization is required from a physician, nurse, or nurse manager. A sufficient number of staff members (a minimum of five) must be present for the physical intervention to protect all individuals and prevent injury. After the physical intervention, staff and patient debriefings are valuable to assist the treatment team in the patient's care plan revisions.
Element 5: safety procedure for emergency medication administration. Besides ensuring safety for all individuals on the treatment unit, medication is an important cornerstone in the treatment and empowerment of psychiatric inpatients. Patients who are nonadherent to medications or withdrawing from drugs of abuse present a particular risk of aggression. When a patient's behavior escalates, medication can help the patient regain safe control of psychiatric symptoms and behaviors. The psychiatrist's role in the safety paradigm of safe and high-quality care involves an initial, proactive, comprehensive clinical assessment, active biopsychosocial intervention both before and during a crisis, and a maintenance safety plan that is "handed off" via a clinical communication to all staff.
Clinical handoff communications involve sharing and discussing additional treatment or risk information among all treatment providers in a timely manner as a patient moves from one treatment setting to another. Sharing and discussion are essential to the management of risk and the provision of safety, especially during staff shift changes, across clinical service departments, and among treatment settings. Clinical handoff communications provide each receiving clinician the opportunity to ask and respond to questions about the patient's past and ongoing treatment and any risk- or safety-related matters (6).
Elements 6 and 7: giving "bad news" and critical communication. There should be a specific and safe procedure to share "bad news" events, such as the patient's loss of a job, unexpected changes in the patient's planned discharge date, modifications in expected housing, continued court-ordered hospitalization, or the death of a loved one. Having a defined procedure reduces the instances and possibility of injury to others. TVBH's "Do's and Don'ts of Giving Bad News" is presented in the box on page 1377.
Do's and Don'ts of Giving "Bad News"
1. Know the patient, listen to the patient, and anticipate the patient's response to the information containing "bad news."
2. Be sensitive and empathic to the way the information is given to the patient. Do not give information in passing, from behind the nursing station, or as you leave the patient's treatment unit.
3. Share the bad news with other team members before giving any information to the patient. Ask for input on how to approach the patient, when to approach the patient, the best environment for giving the information, and whether there is a support person (staff or family) who should be present.
4. Think: location, location, location. Always communicate bad news in an area or space that is visible to others, never behind locked doors or with curtains or blinds closed. The team members should discuss whether the bad news would be best delivered in a more open or more private setting on the unit, depending on the patient and safety needs.
5. Never communicate bad news alone. Always meet with the patient with at least one other person. This additional person can provide support for you and the patient. The support person can be responsible for helping assess the patient's emotional reaction to the news. Be sure that other support staff are readily available and are closely monitoring the situation visually. Staff should ensure a safe exit strategy for all once the bad news is effectively communicated.
6. Provide emotional encouragement and support to the patient after delivering the information. Ask the patient for his or her input about appropriate and healthy ways of coping with the bad news (for example, calling a family member or spending some time alone). Help the patient accept the bad news and explore ways to move forward or take control.
7. Share coping resources that are available to the patient and that can be utilized when needed, such as meeting with a team member or asking for additional treatment time with the therapist.
8. Communicate with and update the other team members about the outcome of the meeting with the patient. Never assume other staff members know what was communicated, the patient's reaction, or the follow-up safety plan.
9. Meet with the patient and discuss potential challenges and risks, as well as resources available to the patient, during evenings or weekends, when there may be fewer staff available. Include new staff and substitute team members in all communications about bad news. This "handoff" communication is essential to safety.
Element 8: monitoring staff and patient safety performance data. It is important to determine the effectiveness of safety guidelines by analyzing staff input and safety performance data. These analyses can be used to improve and update the safety guidelines.
TVBH staff safety performance outcomes showed that the number of staff injuries decreased 90%— from 91 injuries in 2004 to nine injuries in 2008. Incidents defined as OSHA recordable declined by 77%—from 40 to nine. The number of individuals with lost workdays decreased 77%—from 22 to five. In addition, there was a significant positive impact on patient care: episodes of restraint and seclusion were reduced by 36% (from 301 to 191) during this period. The number of patient complaints fell by 37% (from 291 to 181), and the need for codes for staff to assist in a psychiatric emergency (announced over the public-address system) was reduced by 25% (from 346 to 259).
Safety guidelines can be implemented effectively for the injury-free management of patients both before and during a crisis. The implementation of TVBH's safety guidelines helped staff members to stop saying, "Getting hurt is part of the job." Instead, they now say, "No, getting hurt is not part of the job." TVBH continues to foster a culture of safety and a culture of learning actualized by a team approach to staff and patient safety. If our observations are borne out in controlled research studies, then these safety guidelines will become a "best practice."